GW1-2022-07376_Well Construction - GW1_20220809

--�.--.`C�a��LJ�^ -14:.WATER ZONES i
Well Co awe FROM TO DESCRIPTION
ft ft �
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NC Well Contractor Certification Number
15;OUTCER,GASIl�TTG',fo'r mnitiLd seii'"WWS)b12 LII?FR rf a'licahle'y ".:
Morgan Well &Pump, Inc. FROM TO I DIAMETER z>�cxlaFss MATF1ZIAL
Company Name +1144 f 61181 rn sdr2l pvc
lo'.`IRM II�G. •O&•TUB eoth'er'41 A-sed loo' F
2.Well Construction Permit#:_�•e l� L FROM TO DIAnIETER THICTCMss r• MATERL41
List all applicable well construction permits'(ta WC Coutuv State,Ymtance,etc} ft ft
3.Well Use(check well use): fi• fr• in.
1'7•SCREEIQ',:�.: - . .r'•.=.`: = .•:,`:.•i•�:� ..;1:'� .:;.:
Water Supply Well: FROM TO DIAME[hR SLOT SIZE THICKNESS MATERIAL.
Agricultural MMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) M.
I Xndustn Commercial I Residential Water Supply(sh—d) GROUT-.`fAquifer
OD FROM TOMATERIAL E1�I..4CEMENTMET80D&AMOUNT
ter Supply Well: o ft 20 ftbentonite P-1
oring Recovery ft ft
n.Well: ft ft
r Recharge Groundwater Remedia#ioni Sto a and Recov S 19:SAND/GRAVEL'PACg>rag ery D I almityBarrier FROM TO MATERIAL EH�LACEMENT METHOD
r Test DStormwater Drainage ftmental Technology OSubsidence Control ft ft
rmal(Closed Loop) 13Tracetiiadditional sheets�tFROM TO DESCRIPTION(eolo,hardnesssaiUroek grain sizrmal(Heating/Cooling Return) Other(explain under#21 Remarks) b ft
4.Date Well(s)Completed: Well ID# ` ft17.5
ft r
52 Well Location:
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AV
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Facility/Owner a Facility ID#(if applicable) ft ft
0�2� ft. ft. a .
Ph si al Address,City,and Zip ft ft y S
County Parcel Identificatim No.(PIN) a.9 2022_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la0ong is sufficient) I(1�Cfr�i»:IC l r '` '" m;
L• 'N SSO. t�d3 l W
5
6.Is(are)the well(s)*Permanent or OTemporary Signs f rtified We}1 Contractor Da
B owing is form,I hereby certify that the we Z(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ®No wuh IS 4 C O2C.0100 or IS 4 NCAC 02C•.0200 Well Construction Standards and that a
Ifthis is a repair fzH out known well consn•ucrion iriformation and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
drilled: 11 SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface: V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dif$erew(eras e-3@200'and 2@100D constriction to the following.
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
.Ifwarer lever is above cash:g,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this foim within 30 days of completion of well
12.Well construction method: A q construction to the following:
(Le.auger,rotary,cable,directpusb,eta)
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) 'above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: Tdr— completion of well construction to the(county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016
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